ModifiedCignaPolicy IP0206

Weight Loss Glucagon-Like Peptide-1 Agonists BMI ≥ 30

Defines Cigna's prior authorization, medical necessity, and documentation requirements for liraglutide (Saxenda/generic), semaglutide (Wegovy injection and tablet), and tirzepatide (Zepbound) when used for weight loss and related FDA-indicated comorbid conditions.

Policy Summary

PayerCigna

PolicyWeight Loss Glucagon-Like Peptide-1 Agonists BMI ≥ 30

Policy CodePolicy IP0206

Change TypeAdded Wegovy tabletadded Zepbound indicationsupdated MASH/NASH documentationclarified concomitant-use NMN

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain prior authorization and required documentation (including fibrosis staging for MASH/NASH when applicable) before initiating Saxenda, Wegovy (injection or tablet), or Zepbound.

SourceLink

POLICY UPDATE CHANGES

Wegovy tablet criteria and Wegovy tablet were added to the policy.

Zepbound (tirzepatide) FDA‑approved indications including weight loss and obstructive sleep apnea were added with initial and continuing therapy criteria.

MASH/NASH documentation requirements were updated with specific tests and time windows (liver biopsy within 3 years, VCTE/MRE/ELF within 6 months with ELF score range).

Concomitant use of GLP-1 agonists or GLP-1/GIP agonists with each other is explicitly considered not medically necessary.

3drugs targeted

BMI ≥ 30BMI threshold

Prior Authorizationauthorization

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

initial approval lengths

≥5%/≥10%continuation response

Specialist reqMASH/NASH specialist

Coverage Criteria

General medical necessity statement

GLP-1 receptor agonists are considered medically necessary when ONE of the following is met (I, II, III, or IV):

Overall medical necessity grouping: ONE of the following is met (I, II, III, or IV)

See agent-specific sections I–IV for detailed criteria.

This policy addresses liraglutide (Saxenda, generic), semaglutide (Wegovy injection and Wegovy tablet), and tirzepatide (Zepbound). Prior Authorization is required for these products.

Prior authorization requirement referenced in policy statement.

I. Liraglutide (Saxenda, generic) coverage

Liraglutide (Saxenda, generic) is medically necessary when ONE of the following is met

Liraglutide: Adult initial therapy: Initial Therapy: Approve for 4 months when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; (iii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight-related comorbidity); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet; (v) preferred product criteria is met.see BMI thresholds

Baseline refers to before any GLP-1 or GLP-1/GIP agonist.

Liraglutide: Adult continuation (currently receiving): Patient is currently receiving liraglutide: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight-related comorbidity); (iii) patient has lost ≥ 4% of baseline body weight; (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.≥4% weight loss

If patient has not completed 4 months of initial therapy, assess under initial therapy criteria.

Liraglutide: Pediatric initial therapy: Initial Therapy (ages ≥12 and <18): Approve for 4 months when ALL of: (i) patient is ≥ 12 years and < 18 years; (ii) trial of behavioral modification and dietary restriction ≥ 3 months; (iii) at baseline patient had a BMI ≥ 95th percentile for age and sex; (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet; (v) preferred product criteria is met.pediatric BMI ≥95th percentile

Baseline refers to before any GLP-1 or GLP-1/GIP agonist.

Liraglutide: Pediatric continuation: Patient is currently receiving liraglutide (ages 12–17): Approve for 1 year when ALL of: (i) patient is ≥ 12 years and < 18 years; (ii) at baseline patient had a BMI ≥ 95th percentile for age and sex; (iii) patient has had a reduction in BMI of ≥ 1% from baseline; (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.≥1% BMI reduction

If patient has not completed 4 months of initial therapy, assess under initial therapy criteria.

II. Wegovy (injection) coverage

Wegovy (injection) is medically necessary when ONE of the following is met

Wegovy injection: Adult initial therapy: Initial Therapy: Approve for 7 months when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; (iii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight-related comorbidity); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.see BMI thresholds

Baseline refers to before any GLP-1 or GLP-1/GIP agonist.

Wegovy injection: Adult continuation: Patient is currently receiving Wegovy injection: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight-related comorbidity); (iii) patient has lost ≥ 5% of baseline body weight; (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.≥5% weight loss

If patient has not completed 7 months of initial therapy, assess under initial therapy criteria.

III. Wegovy (tablet) coverage

Wegovy tablet is medically necessary when ONE of the following is met

Wegovy tablet: Adult initial therapy: Initial Therapy: Approve for 6 months when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; (iii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight-related comorbidity); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.see BMI thresholds

Baseline refers to before any GLP-1 or GLP-1/GIP agonist.

Wegovy tablet: Adult continuation: Patient is currently receiving Wegovy tablet: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight-related comorbidity); (iii) patient has lost ≥ 5% of baseline body weight; (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.≥5% weight loss

If patient has not completed 6 months of initial therapy, assess under initial therapy criteria.

IV. Zepbound coverage (header present)

Zepbound (tirzepatide) is considered medically necessary when ONE of the following is met

Zepbound: Header: ONE of the following is met — see weight‑loss and other indication subsections for full criteria.

Full agent-specific criteria follow in subsequent sections.

Zepbound: Weight Loss

Zepbound — Weight loss in an adult with overweight or obesity

Zepbound approval grouping: Approve when ONE of the following (A or B) is met

Initial and continuation paths described below.

A) Initial Therapy for Zepbound: Initial Therapy: Approve for 8 months when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; (iii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight‑related comorbidity); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.

Baseline refers to before any GLP-1 or GLP-1/GIP agonist.

B) Patient Currently Receiving Zepbound (continuation): Patient is currently receiving Zepbound: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight‑related comorbidity); (iii) patient has lost ≥ 5% of baseline body weight; (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.

Wegovy: MACE Risk Reduction

Wegovy — Major adverse cardiovascular event (MACE) risk reduction in patients with established cardiovascular disease

Wegovy MACE approval grouping: Approve for 1 year if ONE of the following (A or B) is met

Initial and continuation paths described below.

A) Initial Therapy for MACE: Initial Therapy: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has a current BMI ≥ 27 kg/m2; (iii) patient has had a prior myocardial infarction OR prior stroke (excluding TIA) OR symptomatic peripheral arterial disease as evidenced by intermittent claudication with ABI < 0.85 OR peripheral arterial revascularization OR amputation due to atherosclerotic disease; (iv) medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease; (v) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.BMI ≥27

Prior stroke excludes TIA.

B) Patient Currently Receiving Wegovy (injection or tablet): Patient is currently receiving Wegovy: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient had a BMI ≥ 27 kg/m2; (iii) patient meets same vascular history criteria as above (prior MI, prior stroke excluding TIA, or symptomatic peripheral arterial disease as evidenced by ABI <0.85, revascularization, or amputation); (iv) medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease; (v) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.

Wegovy: Obstructive Sleep Apnea

Wegovy — Obstructive sleep apnea (OSA), moderate to severe, in a patient with obesity

OSA approval grouping: Approve for 1 year if ONE of the following (A or B) is met

Initial and continuation paths described below.

A) Initial Therapy for OSA: Initial Therapy: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has a current BMI ≥ 30 kg/m2; (iii) patient has had a sleep study showing diagnosis of moderate to severe OSA AND an apnea‑hypopnea index (AHI) ≥ 15 events/hour; (iv) patient does NOT have central sleep apnea or Cheyne‑Stokes respiration; (v) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.AHI ≥15

Moderate OSA AHI ≥15; severe AHI ≥30.

B) Patient Currently Receiving Wegovy for OSA (continuation): Patient is currently receiving Wegovy for OSA: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient had a BMI ≥ 30 kg/m2; (iii) patient has completed ≥ 1 year of therapy AND has lost ≥ 10% of baseline body weight; (iv) prescriber documents stability in OSA signs or symptoms; (v) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.

Initial and Continuing Therapy — Weight Loss

General weight‑loss indications for Wegovy, Saxenda (liraglutide), and Zepbound

Initial Therapy (general): Initial Therapy: Approve when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; (iii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight‑related comorbidity); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.

Baseline refers to before initiation of the specified agent.

Patient Currently Receiving (general continuation): Continuation (patient currently receiving): Approve when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient met the BMI criteria (baseline ≥30 OR baseline ≥27 with ≥1 weight‑related comorbidity); (iii) patient has met agent‑specific weight‑loss response thresholds (e.g., ≥4% for liraglutide adults; ≥5% for Wegovy and Zepbound adults); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.drug‑specific response thresholds

Continuation durations often 1 year.

Weight-loss medications are specifically excluded under many benefit plans. Coverage for liraglutide (Saxenda/generic), Wegovy (injection or tablet), and Zepbound depends on the member’s specific benefit plan document; the plan’s terms supersede this Coverage Policy when there is a conflict. Providers should verify the customer’s benefit plan to determine whether weight‑loss medication benefits are available before submitting a request for prior authorization.

This policy targets liraglutide (Saxenda/generic), Wegovy (semaglutide injection and tablet), and Zepbound (tirzepatide). Other GLP‑1 agonists that do not carry an FDA‑approved indication for weight loss are not the focus of this policy and are not covered by these criteria.

Use of liraglutide (Saxenda, generic), Wegovy, and Zepbound for any indication not listed in the FDA‑approved uses covered by this policy is considered not medically necessary. Requests for off‑label uses that are not specified in the policy will not meet medical‑necessity criteria.

Claims submitted for services billed for conditions or diagnoses that are not covered under this Coverage Policy will be denied as not covered. When billing, providers must submit the most appropriate covered diagnosis and procedure codes per the applicable Coverage Policy.

Concomitant use of GLP‑1 agonists with other GLP‑1 agonists or GLP‑1/GIP agonists (including combining these agents with each other) is considered not medically necessary. Combination therapy with multiple GLP‑1 or GLP‑1/GIP products may result in denial of coverage.

Coding and Clinical Thresholds

Covered/Required Codes (not listed in excerpt)mixed

affected codes

Policy notes that reimbursement is only provided if requested services are submitted with covered diagnosis and/or procedure code(s); specific codes not listed in this fragment.

Apnea‑Hypopnea Index (AHI) — Diagnostic threshold for moderate to severe OSA

AHI diagnostic thresholdApnea‑Hypopnea Index (AHI) ≥ 15 events/hour required to define moderate to severe OSA for initial therapy

AHI measurement methodsDiagnosis may be by polysomnography, home sleep apnea test, or other methods meeting local guidelines

Severe OSA thresholdSevere OSA defined as AHI ≥ 30 events/hour

BMI categories — Overweight and obesity class ranges (policy focus on BMI ≥ 30)

OverweightBMI ≥ 25.0 to ≤ 29.9 kg/m2

Class I obesityBMI ≥ 30.0 to ≤ 34.9 kg/m2

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required for benefit coverage of liraglutide (Saxenda/generic), Wegovy (injection and tablet), and Zepbound. Absence of an approved prior authorization may result in claim denial. All approvals are provided for the duration noted in the clinical criteria (when months are used, 1 month = 30 days).

PA required for: liraglutide (Saxenda/generic), Wegovy (injection/tablet), Zepbound
Approvals provided for specified durations per product and indication as listed in the FDA‑Approved Indications sections (e.g., 4, 6, 7, or 8 months or 1 year where specified)

Documentation Required

Documentation Required for Certain Uses

Documentation is required for certain approvals and must include patient‑specific identifying information. Acceptable documentation includes, but is not limited to, chart notes, laboratory results, medical test results, claims records, and prescription receipts. Specific situations requiring documentation include Saxenda for weight loss and Wegovy for MASH/NASH (e.g., fibrosis staging via biopsy, VCTE, MRE, or ELF where indicated).

Background

Liraglutide, semaglutide (Wegovy), and tirzepatide (Zepbound) are agents acting on the glucagon‑like peptide‑1 (GLP‑1) receptor; tirzepatide also has activity at the glucose‑dependent insulinotropic polypeptide (GIP) receptor. These medications are indicated as adjuncts to diet and increased physical activity for weight reduction in adults with overweight or obesity. In addition, Wegovy and Zepbound have specific FDA‑approved secondary indications (for example, Wegovy for cardiovascular risk reduction and MASH/NASH in select patients, and Zepbound for certain obstructive sleep apnea indications) that are addressed by distinct coverage criteria and documentation requirements in this policy.

Definitions

Specified gender in criteria — definition (males and females)

Specified gender definitionMales and females defined by biological traits regardless of gender identity or expression when an asterisk denotes a specified gender in criteria

Asterisk usageAn asterisk next to gender in clinical criteria indicates the above biological definition applies

ApplicabilityDefinition applies where clinical criteria specify gender for indications or dosing

Specified gender — clarification of gender specifier in criteria

Clarification on gender specifierWhere a specified gender is required in criteria, it refers to biological traits (male or female) irrespective of the individual's gender identity or expression

Notation guidance

Initial Therapy Criteria

Initial dosing and escalation

Initial dosing and escalation schedules per FDA prescribing information

Wegovy injection dosing/escalation: Wegovy injection: recommended escalation over 16 weeks to reach 2.4 mg QW (start of Week 17); maintenance dose 2.4 mg QW (or 1.7 mg QW if not tolerated); consider delaying escalation by 4 weeks for tolerability; Wegovy tablet escalation described separately.16 weeks to 2.4 mg injection; delay escalation 4 weeks if needed

Switching guidance between injection and tablet provided in prescribing information.

Wegovy tablet dosing/escalation: Wegovy tablet: recommended escalation over 90 days to reach 25 mg QD (start of Day 91); if not tolerated, consider delaying escalation or switching formulations as described.90 days to 25 mg tablet

If additional weight reduction needed in patients with T2DM on Wegovy 25 mg tablet, consider switching to Wegovy injection and follow injection escalation.

Continuation Therapy Criteria

Liraglutide continuation rules

Liraglutide continuation guidance from prescribing information

Liraglutide continuation assessment: For adults, evaluate weight change at 16 weeks on liraglutide; discontinue if the patient has not lost ≥ 4% of baseline body weight. For pediatric patients, evaluate BMI after 12 weeks on maintenance dose; discontinue if the patient has not had a reduction in BMI of ≥ 1% from baseline.16 weeks adult; 12 weeks pediatric

Guidance derived from liraglutide prescribing information.

Continuation therapy rules

Continuation/maintenance approval rules for patients already receiving therapy

Liraglutide continuation: Approve for 1 year if patient ≥ 18 years and at baseline met BMI criteria and has lost ≥ 4% of baseline body weight; medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.

Step Therapy and Switching

Issue	Policy guidance
Switching between Wegovy injection and Wegovy tablet
Per product labeling, patients may switch from Wegovy 2.4 mg SC injection to Wegovy 25 mg tablet one week after discontinuing the injection; initiate 25 mg orally once daily. Patients may switch from Wegovy 25 mg tablet to Wegovy 2.4 mg SC injection the day after discontinuing the tablet; initiate injection and follow injection dose‑escalation schedule.
Dose escalation delays for tolerability
If a patient does not tolerate a dose during escalation, consider delaying escalation: for Wegovy injection consider delaying escalation by 4 weeks; for Wegovy tablet consider delaying escalation as needed per prescribing information (tablet escalation reaches 25 mg at Day 91).
Coadministration with other GLP‑1/GLP‑1‑GIP agonists
None of the GLP‑1 or GLP‑1/GIP agonists are recommended for coadministration with other GLP‑1 or GLP‑1/GIP agonists.

Issue	Policy guidance
Employer‑plan requirement for Saxenda (liraglutide) brand use
For employer plans that adopt the Saxenda-specific requirement, the patient must try the bioequivalent generic liraglutide subcutaneous injection prior to coverage of brand Saxenda unless the prescriber documents that the patient cannot take the generic due to a formulation difference in inactive ingredients (e.g., dyes, fillers, preservatives) leading to a significant allergy or serious adverse reaction. Documentation is required.

Issue

Policy guidance

Employer‑plan requirement for Saxenda (liraglutide) brand use

For employer plans that adopt the Saxenda-specific requirement, the patient must try the bioequivalent generic liraglutide subcutaneous injection prior to coverage of brand Saxenda unless the prescriber documents that the patient cannot take the generic due to a formulation difference in inactive ingredients (e.g., dyes, fillers, preservatives) leading to a significant allergy or serious adverse reaction. Documentation is required.

Requirement	Policy guidance
Behavioral modification and dietary restriction trial prior to initial therapy
Initial therapy for weight loss requires that the patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months before initiation; the medication must be used concomitantly with behavioral modification and a reduced‑calorie diet.

Policy Summary

PayerCigna

PolicyWeight Loss Glucagon-Like Peptide-1 Agonists BMI ≥ 30

Policy CodePolicy IP0206

Change TypeAdded Wegovy tabletadded Zepbound indicationsupdated MASH/NASH documentationclarified concomitant-use NMN

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain prior authorization and required documentation (including fibrosis staging for MASH/NASH when applicable) before initiating Saxenda, Wegovy (injection or tablet), or Zepbound.

SourceLink

On This Page

Wegovy injection: Pediatric initial therapy: Initial Therapy (ages ≥12 and <18): Approve for 7 months when ALL of: (i) patient is ≥ 12 years and < 18 years; (ii) trial of behavioral modification and dietary restriction ≥ 3 months; (iii) at baseline patient had a BMI ≥ 95th percentile for age and sex; (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.pediatric BMI ≥95th percentile

Baseline refers to before any GLP-1 or GLP-1/GIP agonist.

Wegovy injection: MACE risk reduction: MACE (CV risk reduction): Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) current BMI ≥ 27 kg/m2; (iii) patient has had a prior myocardial infarction OR prior stroke (excluding TIA) OR symptomatic peripheral arterial disease evidenced by intermittent claudication with ABI < 0.85 OR peripheral revascularization OR amputation for atherosclerotic disease; (iv) medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease; (v) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.BMI ≥27

Applies to patients with established cardiovascular disease.

Wegovy injection: MASH/NASH: MASH/NASH: Initial Therapy Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) patient does not have cirrhosis (F4); (iii) stage F2 or F3 fibrosis documented prior to initiating therapy by liver biopsy within 3 years OR VCTE/MRE/ELF within 6 months (ELF score 9.2–10.5); (iv) one or more metabolic risk factors are managed; (v) alcohol use below sex‑specific thresholds; (vi) medication will be used in combination with appropriate diet and exercise therapy; (vii) prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist. Continuation: Approve if patient has completed ≥1 year of therapy and meets analogous criteria without worsening fibrosis.ELF 9.2–10.5 when used; documented F2–F3 fibrosis

Documentation and specialist involvement required.

Wegovy tablet: MACE risk reduction: MACE (CV risk reduction) same criteria as Wegovy injection: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) current BMI ≥ 27 kg/m2; (iii) prior myocardial infarction OR prior stroke (excluding TIA) OR symptomatic peripheral arterial disease (ABI < 0.85, peripheral revascularization, or amputation for atherosclerotic disease); (iv) medication used in combination with optimized pharmacotherapy for established cardiovascular disease; (v) medication used concomitantly with behavioral modification and a reduced‑calorie diet.BMI ≥27

Applies to patients with established cardiovascular disease.

Continuation approval duration 1 year.

Continuation approval 1 year; baseline refers to before Wegovy initiation.

Continuation approval 1 year.

Class II obesityBMI ≥ 35.0 to ≤ 39.9 kg/m2

Class III obesityBMI ≥ 40 kg/m2

Baseline BMI thresholds — adults and pediatrics

Adult baseline BMI — primary thresholdBaseline BMI ≥ 30 kg/m2 prior to initiation of the specified GLP‑1 or GLP‑1/GIP agent

Adult baseline BMI — with comorbidityBaseline BMI ≥ 27 kg/m2 if the patient has at least one weight‑related comorbidity (e.g., hypertension, type 2 diabetes, dyslipidemia, OSA, cardiovascular disease, etc.)

Pediatric baseline BMIPediatrics (ages 12 to <18): baseline BMI ≥ 95th percentile for age and sex

Response thresholds (weight loss) — Agent‑specific continuation criteria

Liraglutide (Saxenda) continuation thresholdAdult continuation: patient has lost ≥ 4% of baseline body weight (evaluate at 16 weeks)

Wegovy (injection/tablet) continuation thresholdAdult continuation: patient has lost ≥ 5% of baseline body weight

Zepbound continuation threshold (general weight‑loss)Patient currently receiving: has lost ≥ 5% of baseline body weight

Zepbound continuation threshold for OSAFor continued Zepbound in OSA after ≥ 1 year of therapy: patient has lost ≥ 10% of baseline body weight

BMI — Policy baseline thresholds for adult indications

Primary adult BMI thresholdBaseline BMI ≥ 30 kg/m2

Alternate adult BMI threshold with comorbidityBaseline BMI ≥ 27 kg/m2 plus at least one weight‑related comorbidity

Applies to initiation and continuation rulesBaseline refers to BMI prior to initiating any GLP‑1 or GLP‑1/GIP agonist

Weight loss response — Zepbound continuation thresholds (including OSA)

Zepbound continuation (general)Patient currently receiving Zepbound: approve for 1 year if patient has lost ≥ 5% of baseline body weight

Zepbound continuation for OSAFor obstructive sleep apnea, continuation requires ≥ 10% baseline body weight loss after ≥ 1 year of therapy plus documented stability in OSA signs/symptoms

Zepbound initial therapy weight‑loss requirementInitial therapy requires baseline BMI criteria plus behavioral modification trial ≥ 3 months (continuation thresholds apply after initial period)

Apnea‑Hypopnea Index (AHI) severity — Moderate and severe thresholds

Moderate AHI thresholdModerate OSA: AHI ≥ 15 events/hour

Severe AHI thresholdSevere OSA: AHI ≥ 30 events/hour

Clinical testing noteAHI is determined by sleep study (polysomnography or home sleep apnea test) per local guidelines

ELF score and MASH/NASH — Testing and documented range required

ELF score rangeEnhanced Liver Fibrosis (ELF) test score ≥ 9.2 to ≤ 10.5 required when used as documentation for F2–F3 fibrosis

Other acceptable tests and time windowsAlternatively, documentation may be liver biopsy within 3 years or VCTE/MRE within 6 months preceding treatment

PurposeRequired to document stage F2 or F3 fibrosis prior to initiating Wegovy (or Rezdiffra) for MASH/NASH

Documentation may include chart notes, labs, medical test results, claims records, prescription receipts
Wegovy for MASH/NASH: documentation of fibrosis staging (liver biopsy within 3 years, VCTE/MRE within 6 months, or ELF within 6 months with documented score)
All documentation must include patient‑specific identifying information

Note

Dosing, Dose‑Escalation, Switching, and Coadministration Guidance

Follow product‑specific prescribing and dose‑escalation guidance. Do not coadminister GLP‑1 or GLP‑1/GIP agonists with one another. If intolerance occurs during escalation, consider delaying escalation per product guidance or reducing to the prior tolerable dose. Switching between Wegovy injection and Wegovy tablet has defined timing.

Wegovy injection: recommended escalation over 16 weeks to 2.4 mg QW; maintenance 2.4 mg (or 1.7 mg) QW; tablet escalation over 90 days to 25 mg QD; switching: one week after stopping 2.4 mg injection, start 25 mg tablet; day after stopping 25 mg tablet, initiate injection dose escalation
Liraglutide (Saxenda/generic): escalation over 4 weeks to 3 mg QD (3 mg maintenance adult); evaluate weight at 16 weeks and discontinue if <4% weight loss from baseline; pediatric specifics apply
Zepbound: start 2.5 mg QW then increase per schedule to maintenance doses of 5, 10, or 15 mg QW (max 15 mg); escalation steps occur at specified weeks (5 mg at Week 4, 10 mg Week 12, 15 mg Week 20)
None of the GLP‑1 or GLP‑1/GIP agonists are recommended for coadministration with other GLP‑1 or GLP‑1/GIP agonists

Prior Authorization

Employer Plan: Saxenda Bioequivalent Generic Trial Required

Employer‑plan specific requirement: For Saxenda (liraglutide SC injection), the patient must have tried the bioequivalent generic liraglutide SC injection and be unable to take it due to a formulation difference in inactive ingredients that would cause a significant allergy or serious adverse reaction per the prescriber. Documentation of this intolerance or contraindication is required.

Employer plan: trial of bioequivalent generic liraglutide SC injection is required prior to Saxenda coverage unless documented intolerance/serious adverse reaction to inactive ingredients is provided
[documentation required]

Step Therapy

Behavioral Modification Prerequisite

Behavioral modification and dietary restriction for at least 3 months is a prerequisite prior to initiating therapy for weight‑loss indications. Ongoing use must be concomitant with behavioral modification and a reduced‑calorie diet.

Initial therapy criteria require documentation of a ≥3 month trial of behavioral modification and dietary restriction prior to starting medication
Medication approvals are conditioned on concomitant use with behavioral modification and reduced‑calorie diet

Policy text uses an asterisk to flag specified gender terms within the clinical criteria

Clinical intentEnsures consistent interpretation when gender‑specific requirements are present in the criteria

Baseline BMI — definition prior to initiation

Baseline BMI definitionBaseline BMI refers to the BMI measured prior to initiation of the specified GLP‑1 or GLP‑1/GIP agent

Use in criteriaBaseline BMI is used to determine eligibility for initial therapy and to establish the denominator for percent weight‑loss response calculations

Applies to all agentsExplicitly noted for Wegovy and Zepbound and used throughout the weight‑loss criteria

MASH/NASH documentation — diagnostic confirmation and staging requirements

MASH/NASH fibrosis staging requirementPatient must have documentation of stage F2 or F3 fibrosis prior to initiating Wegovy or Rezdiffra

Acceptable diagnostic tests and time windowsLiver biopsy within 3 years OR VCTE, MRE, or ELF performed within 6 months preceding treatment (ELF score 9.2–10.5 when used)

Specialist involvement and documentationWegovy for MASH/NASH must be prescribed by or in consultation with an appropriate specialist and documentation must include patient identifiers and test results

Liraglutide dosing/escalation: Liraglutide: escalation over 4 weeks to maintenance 3 mg QD for adults; evaluate weight change at 16 weeks and discontinue if <4% baseline weight loss; pediatric escalation and maintenance dosing and evaluation timelines specified in PI.4 weeks escalation; evaluate at 16 weeks (adult)

If patient cannot tolerate target dose, consider dose reduction or discontinuation per PI.

Zepbound dosing/escalation: Zepbound: start 2.5 mg QW, increase to 5 mg QW after 4 weeks, then increase by 2.5 mg increments every ≥4 weeks to maintenance doses of 5, 10, or 15 mg QW; maximum 15 mg QW; OSA maintenance commonly 10 or 15 mg QW.4‑week increments; maintenance by Week 20 for 15 mg

None of the GLP‑1 or GLP‑1/GIP agonists are recommended for coadministration with other GLP‑1/GLP‑1‑GIP agents.

Initial therapy rules

Initial therapy approval durations and eligibility

Liraglutide initial (adult): Approve for 4 months when ALL criteria for initial therapy are met (age ≥18; behavioral modification/diet trial ≥3 months; baseline BMI criteria; concomitant behavioral modification and reduced‑calorie diet; preferred product criteria as applicable).4 months

See pediatric criteria for ages 12–17.

Wegovy injection initial (adult): Approve for 7 months when ALL criteria for initial therapy are met (age ≥18; behavioral modification/diet trial ≥3 months; baseline BMI criteria; concomitant behavioral modification and reduced‑calorie diet).7 months

See pediatric criteria for ages 12–17.

Wegovy tablet initial (adult): Approve for 6 months when ALL criteria for initial therapy are met (age ≥18; behavioral modification/diet trial ≥3 months; baseline BMI criteria; concomitant behavioral modification and reduced‑calorie diet).6 months

See pediatric criteria for ages 12–17.

Zepbound initial (adult): Approve for 8 months when ALL criteria for initial therapy are met (age ≥18; behavioral modification/diet trial ≥3 months; baseline BMI criteria; concomitant behavioral modification and reduced‑calorie diet).8 months

Baseline refers to before any GLP‑1 or GLP‑1/GIP agonist.

Zepbound initial therapy

Zepbound initial: Initial Therapy: Approve for 8 months when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; (iii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight‑related comorbidity); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.

Approval duration 8 months for initial therapy.

Wegovy/Saxenda initial therapy

Wegovy and Saxenda initial therapy (weight‑loss indications)

Initial therapy general for Wegovy/Saxenda: Initial Therapy: Approve for the agent‑specific duration when ALL of: (i) patient is ≥ 18 years of age; (ii) patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months (when indicated); (iii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight‑related comorbidity); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.agent‑specific durations (4, 6, or 7 months)

See agent sections for exact initial durations.

If patient has completed <4 months of initial therapy, assess under initial therapy criteria.

Wegovy injection continuation: Approve for 1 year if patient ≥ 18 years and at baseline met BMI criteria and has lost ≥ 5% of baseline body weight; medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.≥5% weight loss

If patient has completed <7 months of initial therapy, assess under initial therapy criteria.

Wegovy tablet continuation: Approve for 1 year if patient ≥ 18 years and at baseline met BMI criteria and has lost ≥ 5% of baseline body weight; medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.≥5% weight loss

If patient has completed <6 months of initial therapy, assess under initial therapy criteria.

Continuation therapy

Continuation (Patient Currently Receiving) rules differ by agent and indication; many continuations require meeting specified weight‑loss thresholds and ongoing use with behavioral modification.

Zepbound continuation: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient had a BMI ≥ 30 kg/m2 OR (baseline BMI ≥ 27 kg/m2 AND at baseline had at least one weight‑related comorbidity); (iii) patient has lost ≥ 5% of baseline body weight; (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.≥5% weight loss

Continuation approval 1 year.

Wegovy continuation for weight loss: Approve for 1 year when ALL of: (i) patient is ≥ 18 years of age; (ii) at baseline patient met BMI criteria; (iii) patient has lost ≥ 5% of baseline body weight (or agent‑specific threshold such as ≥10% for OSA continuation); (iv) medication will be used concomitantly with behavioral modification and a reduced‑calorie diet.agent‑specific (≥5% or ≥10% depending on indication)

If patient has not completed the required initial therapy duration, assess under initial therapy criteria.